Announcer: [00:00:00] Welcome to episode ten of empowEAR Audiology with Dr. Carrie Spangler.

Carrie: [00:00:16] Hi everyone. Welcome to the empowEAR audiology podcast. My name is Dr. Carrie Spangler and I'm your host. I am a passionate audiologist with a lifelong journey of living with hearing challenges in this vibrant hearing world. I just want to thank all of you for listening, and I hope that you will subscribe, that you invite others to listen and leave a positive review. I also want to invite all of you to engage on the Empower Your Audiology Facebook page. So let's get started with today's episode of Empower Your Audiology. As an educational audiologist, one of the words that I really have a problem with and my profession is the word mild. And if you look up the word mild in a dictionary, you will find that as it relates to illness or pain, it is described as not serious or not dangerous. And I feel like this descriptor has significant consequences if we equate mild hearing loss as not serious. So today on the podcast, I am really excited to have Dr. Beth Walker with me. And I'm going to tell you a little bit about Dr. Walker before we get started. So Dr. Walker is an assistant professor in the Department of Communication Sciences and Disorders at the University of Iowa in Iowa City, Iowa. And she's the director of the pediatric audiology lab. Her research focuses on pediatric oil habilitation, specifically examining factors that relate to individual differences in listening and language outcomes for children who are deaf or hard of hearing. She is an investigator on a number of research projects funded by the National Institutes of Health, including the Ten-Year Longitudinal Investigation The Outcomes of Children with Hearing Loss Study. She has authored over 50 peer reviewed publications and coauthored a textbook on pediatric amplification. So it is my honor and pleasure to introduce to all of you Dr. Beth Walker. So welcome.

Beth: [00:02:36] Hi. Thank you for having me. I wish the audience could see our faces right now because we have these giant grins on our faces.

Carrie: [00:02:45] I know and we can't see each other in person, so it's good to see each other in video right now.

Beth: [00:02:49] Exactly.

Carrie: [00:02:50] Yes. So, Beth, I was just trying to think like, how did we first meet?

Beth: [00:02:56] I know how we met. So we were in Florida. It was the Educational Audiology Association, and they had this little it wasn't. Carol Johnson had this little it wasn't a conference. It was like this little mini meeting before.

Carrie: [00:03:11] Do you remember that? I remember that.

Beth: [00:03:13] And I can't remember where we were in Florida. I remember it was super hot outside and I was like, yeah, it might have been. And we so we were at that meeting and that's where I, that's where I met you the first time. Because. Because then honestly, I remember that we went and had to the bar afterwards and had the hotel bar. You can edit that part out each other a lot better.

Beth: [00:03:39] I only came for that day. I didn't stay for the conference for, so I just came for that little meeting that one day and then left the next morning.

Carrie: [00:03:50] And then we saw each other at Asha in Memphis, right? That was another one.

Beth: [00:03:56] Oh, yeah. Yeah, that Memphis one. Yeah.

Carrie: [00:03:59] And then I got to bring you to Ohio.

Beth: [00:04:01] And then I got to come to Ohio last year pre-COVID. Yep. And then I was supposed to be in Ohio this fall too, for the I don't remember what it was for. Oh, I know I was supposed to be in Ohio. Yeah, it might have been. And and I think that got bumped off to next year, something I can't remember. Yeah. But so will be back in Ohio again.

Carrie: [00:04:23] Well, I hope so because we will get connected again for sure. Yes. So I have another question for you before we kind of dive into the the meat of the podcast, but can you tell all of our listeners how you actually got started into into audiology? Is it a good story?

Beth: [00:04:41] So I was wondering if you'd ask me this question. So I don't know if it's a good story. Like most people, I kind of fell into audiology. It was not like I dreamed of being an audiologist when I was a little girl. But what I tell all my students was, I actually, when I was a little girl, I dreamed of being a detective and an author, and my favorite things were Nancy Drew mysteries. And so I loved reading them. And I wanted to solve mysteries and write books. And then I got to grad school and realized that was not really a very good or not grad. An undergrad realize that wasn't a very good career plan, so went into psychology instead. And then from psychology somehow fell into speech pathology and audiology. I think what actually happened was I was in psychology. I knew I wanted to go into more of a health care field, and somebody on my dorm room floor was like, if don't get into pharmacy school, I'm going to be a speech pathologist. And I thought, oh, that sounds cool. I'll try that, too, because I knew I didn't want to stay in. I didn't want to be a psychologist. So I ended up going into speech path and then kind of like what happens with a lot of people. I was taking the communication sciences and disorders classes and got really interested in audiology through that, even though I thought at first and with me, the thing was, I honestly couldn't decide if I wanted to be a speech pathologist or an audiologist. And in the back of my mind, I still wanted to be a detective and an author. So what I ended up doing was getting dual certification. I never made a decision, I just became I went to grad school for speech and audiology. I did two cfis in Indiana, so I was I went I worked at Riley Children's Hospital and did a speech pathology, then audiology, and then ended up getting my PhD, which is where I was able to become. It sounds corny, but that was where I was able to become a detective and a writer. And so I really do feel like that's what I do. Like, I feel like it sounds it's so cheesy, but I feel like when I'm doing research, I'm really like, kind of, I've got all these facts and I can put together this puzzle, and that's what I love about research. And I still get to do the writing aspect of it, but I get to do it in this field that I think is super cool, which is audiology and speech pathology.

Carrie: [00:07:07] Exactly and I feel like it's a long history where hearing loss is just, I think, where speech pathology and audiology really overlap so much. So it's great to have both perspectives, especially with all of your research.

Beth: [00:07:22] Yeah. And that's why am really glad I ended up doing both, because what I'm really interested in is how hearing loss impacts listening and language and reading development. And so I feel like if you're going to be a good pediatric audiologist, you need to understand the language side of things. And if you're going to be a good speech pathologist that works with kids, with hearing loss, you need to understand audiology. So I would not do both. I would not recommend nowadays doing dual certification because it would just take too darn long, which is unfortunate. But yeah.

Carrie: [00:07:57] So one of the things that you have been very involved in, and I didn't realize it until I read some of the bio, is the outcome for children with hearing loss study for over ten years now. So can you tell our listeners a little bit more about how you got involved with this study?

Beth: [00:08:18] So this was just actually I was kind of in the right place at the right time. So I was working. I was finishing my PhD, I was probably a year away from finishing my PhD, and I was working as a speech pathologist on the cochlear implant team over at the hospital at University of Iowa. And I was actually doing I love doing transcriptions like phonetic transcriptions, which sounds really weird, but just it's kind of fun. And so somebody was actually Bruce Tomblin, who's a professor here at Iowa, was paying me to do these transcriptions for him. And so I happened to be down in his lab one day, and his project coordinator looked at me and she was like, hey, you're an audiologist too, aren't you? And I was like, yeah. She's like, oh, we have this new research grant called The Outcomes of Children with Hearing Loss Study, and we need an audiologist for it. And she handed me the job description and I looked at it and I'm it was like I think I looked at it for like, 30s. And I was like, this is what I want to do. Like this was my dream research project to be involved in because it was looking at children with mild to severe hearing loss. It was working. It was a multicenter study, so it was working with people at Boys Town National Research Hospital and University of North Carolina.

Beth: [00:09:35] And it was all these people. I kind of knew that honestly, like some of them had academic crushes on, like Mary Pat Mueller. And but I didn't know them really well. And so but I knew like, this would be such a cool job to have because I get to work with all these people that I had really admired. Also, at North Carolina, Melody Harrison was somebody up North Carolina, and she was another person that I just looked up to for such a long time. And so I think I went home and I told my husband, I'm like, okay, I'm changing jobs. I'm going to take this job. They hadn't even offered it to me. But I was like, okay, this is what I want to do. And so that was how I fell into it. It was. Literally like happened to be in the right room at the right time. The stars align. All the stars aligned. And because they had just I think they just started the funding for the project. And so that would have been in 2008. So actually we're going on now 12 years of the study. We didn't start collecting data until 2009, I think. But yeah, the the funding started for the grant in 2008.

Beth: [00:10:39] Wow.

Carrie: [00:10:40] And it's such a all of the research that all of you have done has been so instrumental in everything that we know now as audiologists and educators and those working with kids with hearing loss, but kind of going back a little bit to 2008. What was one of the main questions that you and your team, the researchers, had for going into this study?

Beth: [00:11:07] Well, the main thing was there was a lot of research out there on children who are deaf, children who use cochlear implants. And we really didn't know very much about children with mild to severe hearing loss, particularly what we call the current generation of kids. Kids who are born after 2000, who had access to early intervention, were identified at fairly young ages, had been fit with hearing aids. We didn't really know if those kids were able to keep up with their same age, hearing peers, or if they were showing delays in terms of their language skills. So and we also, it sounds weird. I always say this when I give talks. We really didn't know what the effect of hearing aids were on outcomes, which sounds stupid like. We would really hope that hearing aids would make a difference, but we didn't. We honestly didn't have evidence for that, because almost all of the research studies that have been done in the past on children who are hard of hearing hadn't really described the hearing aids very well. So it didn't we would say, okay, there were 20 kids in this study. Some of them had hearing aids, some of them didn't. It wouldn't say anything about how much they wore their hearing aids, or how well fit the hearing aids were. If the audiologists were using reeler measures to program and fit the hearing aids. And so those were the questions we really had. Are the kids able to keep up with their hearing peers because we knew they were pretty much all using spoken language, and they were pretty much all in regular education settings. And then what impact did the hearing aids have on on their success? So, and what made some of these kids, we knew there was going to be lots of variability. So what made some of these kids succeed and what made some of them struggle.

Beth: [00:12:56] So. Right.

Carrie: [00:12:57] So going back to some of the, the, I guess, invariability what were like the ages of the kids and how many years did you follow these kids? And you said they all had hearing aids, so there was no cochlear implant kids, no.

Beth: [00:13:14] So the way the study started, the kids could be we had what was called an accelerated longitudinal design, so the kids could be anywhere between six months of age and seven years of age. When they enrolled in the project, which was again around like 2009, 2010. And then we followed them longitudinally. So we started off with a wide age range, and that gave us cross-sectional data from basically infancy to first grade. But then we had longitudinal data that tracked so we could track their language growth, their listening growth, just how they were doing over time. And we're still following these kids. So now a lot of some of them are like juniors and seniors and high school, which is crazy to me. Um, but yeah, I mean, some of them were 6 or 7 years old when they started and it's been about ten years. We just completed a study with and a lot of these kids participated in that study on listening effort. It was and it was a project on listening effort. And then we are hoping we submitted a grant last week to the National Institutes of Health to try to follow these kids into junior high and high school.

Beth: [00:14:25] Yeah, that's.

Carrie: [00:14:26] Important to.

Beth: [00:14:27] Know.

Beth: [00:14:28] It is. And I realized I, I realized writing that grant there. We don't know much about adolescence at all. No. So I hear anecdotally that and this makes sense to me when they get to junior high, they don't want to wear their hearing aids or they don't want to wear the remote microphone system at school. But but we don't really have good evidence, research evidence for that. And if they do decide not to wear their equipment, we don't have evidence for why or what impact that has. So so I'm excited, I hope I hope the NIH likes the grant.

Beth: [00:15:04] You never know. I do too because I.

Carrie: [00:15:07] That's one of my passion areas is teens. And I feel like that would be great information. So one other question, like how many kids did you recruit for this? And I'm sure it's been over time too. And how many have actually stayed in the study?

Beth: [00:15:23] So we recruited three. Well, okay. So we had I want to say it was like 4 to 500 people responded to participate. We did not. So the kids in the study all had to have a bilateral hearing loss. We didn't include anybody that had a unilateral hearing loss. Initially we did, and then we didn't keep following those kids. So everybody had a bilateral hearing loss with the study. It all had to be between the mild to severe range and they couldn't have any additional disabilities or in English had to be their first language. And also we we wanted to look at the impact of hearing aids. So we did not include kids that had cochlear implants when they started in the study. We had some that got cochlear implants as the study progressed. So with those criteria, like I said, we had about 500 people, 450 that couldn't contacted us. And with the inclusionary exclusionary criteria, we ended up with 317 kids that were in the study that actually enrolled collected data on them, because some ended up not qualifying because they had additional disabilities or had a cochlear implant. And then we also had a group of 117 children with typical hearing that were matched on socioeconomic status and age, and that was ended up being really important, because one of the things that we've found pretty consistently is when we've looked at the data of our kids, who are hard of hearing that were in the study, if we just look at them compared to test norms like how they did on the Peabody Picture Vocabulary test, they look like they're doing within the average range.

Beth: [00:17:02] But when we compare them to our control group of hearing kids, they're doing significant. They're significant delays compared to that population. So that ended up it was good that we had that normal hearing control group in terms of retention, like who has stayed in the study. I want to say we've can't remember the exact number. And I should know this because this had to go in the grant. I think we've kept about 200 of the kids in the study. Some of them are no longer in the study because they did get cochlear implants and we quit following them. Some of them moved away, some of them we lost to contact. But we've still got a lot of the kids that started in the original study that we're still following. So we're still in contact with.

Beth: [00:17:45] Yeah, right.

Carrie: [00:17:46] Especially over that period of time to to be able to keep getting data and and information about.

Beth: [00:17:55] Yeah. It's helped that a lot of the, some of the original people that started on the project as working on the project are still with the project. So I'm still on the project. Ryan McCreary, who's at Boystown, he started on the project pretty early, and Mary Spratford, who is his research audiologist, and his director of his lab. She's still on the project. So we have a lot of the original people.

Beth: [00:18:19] Which helps.

Beth: [00:18:19] Which helps. Yeah. Yeah.

Carrie: [00:18:21] So so I think one of the things as an educational audiologist kind of being out in the field is that I always have this reaction from teachers and sometimes parents and others, even speech pathologists sometimes. And they're like they read a report and they say, oh, he just has a mild hearing loss. Or and for me that like boils inside of me because I understand the impact of mild. But I guess I wanted to ask you, you know, what are some of those key factors that you found in this study about the impact of mild hearing loss and access to language, basically.

Beth: [00:19:10] So one of the early papers that we published, well, one of the first papers we published as part of the local, the outcomes of Children with Hearing loss study, which I call local just for your audience. People at Boys Town, for whatever reason, call it oql, which takes me too long to say so. I call it local. All the Iowa people call it local. So one of the first papers we published was looking at how much kids wear their hearing aids. And the big takeaway from that was the kids with mild hearing loss weren't wearing their hearing aids. So that was one of the big predictors for hearing aid use time was the severity of the hearing loss. As the hearing loss was more severe, the kids wore their hearing aids more often, and we measured hearing aid use from parent report and from data logging with the hearing aid. And so from that we did a follow up paper because we were really interested, like, okay, well maybe these mild kids don't need to wear their hearing aids. We didn't know, like maybe we're over and hearing aids are expensive. We have I've seen as because as a clinical audiologist, I've seen pushback from physicians and other audiologists sometimes about fitting hearing aids on kids with mild hearing loss. And so we so from that I decided to look at just our mild cohort. So the kids in the study that had a mild hearing loss. And it just so happened that we had a group of kids with mild hearing loss who never wore hearing aids. And then we had a group and our data kind of worked out. And then we had a group that were about six hours per day. So they're probably wearing them at school. And not.

Beth: [00:20:47] A lot of.

Carrie: [00:20:48] People say, well, they just need them at.

Beth: [00:20:49] School. Just school.

Beth: [00:20:50] Yeah. And then we had a group of kids with mild hearing loss that really did wear them full time. And we could tell from the data logging. And so we I ended up taking that data set and just publishing a separate paper on that in, I think 2013 or 2014. I can't remember when that paper came out. And what we found was really large differences between the kids with mild hearing loss, who never wore the hearing aids, and the kids with mild hearing loss, who wore the hearing aids full time. So the kids with mild hearing loss wore the hearing aids full time, were actually about one standard deviation above average in terms of their vocabulary and their grammar skills. But they look just like our typical hearing kids, because the typical hearing kids were also about one standard deviation above average. Which gets to that issue I was talking about where the norms don't always reflect how the kids are doing, whereas the kids with the kids that didn't have hearing aids or didn't wear their hearing aids, they were more like they were about 1 to 2 standard deviations delayed compared to the full time hearing aid wearers. And then they were kind of in the average range compared to the test norms. But to me, that indicates they're not really meeting their full potential. They should look like these kids. They should look like the typical hearing peers if they don't need hearing aids, and they should look like these other kids with mild hearing loss that are wearing the hearing aids full time.

Beth: [00:22:16] So it does indicate to us hearing aids can help, even with just a mild hearing loss. We had another paper we published last year where we looked at called Hearing Aid Dosage, where we measured how much the kids were wearing their hearing aids in combination with how much access they got through the hearing aids based on the speech intelligibility index. And we kind of see this. The data seems to like asymptote around a speech intelligibility index of 0.8 or 80%. And what that means is kids who have access with with no hearing aids on unaided audibility, if they have access to 80% of the speech spectrum, it doesn't seem to make a difference if they have hearing aids or not, or if they wear the hearing aids full time or not. But for the kids that were that had less than 80% access to the speech spectrum without hearing aids on, they seem to need the hearing aids. So. So there seemed to be kind of this like split in the data, like there is a point at which you have a mild hearing loss and you may not. Need to wear hearing aids, but just grouping it all in this big category of mild doesn't really reflect that, because mild is kind of actually kind of a broad range. So so that's where the speech intelligibility index, we're also really into audibility in this research project and how much access you're actually getting through your hearing aids. And that can be measured with the speech intelligibility index.

Carrie: [00:23:41] So just kind of reviewing some of your study before. And you had an acronym called access. So.

Beth: [00:23:51] Oh. Oh yeah.

Beth: [00:23:53] That's I can't take credit for that. That was Mary Pat okay. And now I'm gonna she was the one that came up with that. Mary Pat is really good at coming up with acronyms. And by Mary Pat mean Mary Pat Mueller. Yeah. She was the principal investigator on the original study. She's now retired. She's living in North Carolina with her near her grandkids. I miss her every day. So yeah, Mary Pat came up with that acronym. And are you going to ask me what? I can't remember what it stood for.

Beth: [00:24:21] Well, I can tell you what it means. It's funny because I.

Beth: [00:24:25] So we got this grant on mild hearing loss. And just as you were doing the introduction, I thought, oh, I bet she's going to ask me about the acronym for our mild hearing loss grant. So I pulled up Facebook because I knew I had it on Facebook. And you asked me a different acronym. Oh, well, that's okay.

Carrie: [00:24:41] We can we can we can do the acronym for mild because I didn't think I didn't know you had that acronym actually.

Beth: [00:24:47] Yeah. So we have.

Beth: [00:24:48] So many acronyms I can't keep them all straight.

Beth: [00:24:50] No. Well, tell me the acronym.

Carrie: [00:24:52] That you have for mild because.

Beth: [00:24:54] Wait. No, no.

Beth: [00:24:54] Let me see if I can remember the access. Okay. First. Yeah okay. Is a for audibility.

Beth: [00:25:00] Yes. Oh good. Okay. You got one point is C for consistency.

Carrie: [00:25:08] And that's the third seed or the second seed, I guess. Okay. The first C.

Beth: [00:25:13] Was what's the first C? I can't remember.

Carrie: [00:25:15] Carefully fit hearing.

Beth: [00:25:16] Aids.

Beth: [00:25:16] Oh well that gets out ability. Okay. Okay. Carefully fit.

Beth: [00:25:20] Hearing aids.

Beth: [00:25:21] Consistency of hearing aid use. E is c I know one of them is like super sized services. Is that one of them?

Beth: [00:25:31] Yeah.

Carrie: [00:25:32] So e was environment conducted through language learning.

Beth: [00:25:36] Okay.

Beth: [00:25:37] Yeah. Want wouldn't remember that one. Yeah.

Carrie: [00:25:40] Do you remember one of the S's.

Beth: [00:25:41] It's one one of the S's. Super. Something about super sized services or something.

Beth: [00:25:46] Service provision.

Beth: [00:25:47] Oh, okay. Yeah.

Beth: [00:25:49] And then another one.

Carrie: [00:25:50] Was selected areas of language and.

Beth: [00:25:52] Morphology.

Beth: [00:25:54] Oh, and morphology is weakness. Wow. Did really bad with that. That's okay. Think. Got one letter.

Carrie: [00:26:00] Well, then tell me about the one. The mild.

Beth: [00:26:03] One.

Beth: [00:26:04] Our newest acronym. So our newest acronym is called fast Track.

Beth: [00:26:09] And this is fast track.

Carrie: [00:26:11] Fast track.

Beth: [00:26:12] Fast track. Oh. And this is our new grant that we just got funded through the National Institutes of Health this summer. And it's looking at kids just with mild hearing loss. And don't mean just a mild hearing loss. Mean only mild hearing loss is the focus of the research study. So and a lot of it came out of the research we've been doing where we mean the paper that we published looking at the non-users versus the full time users, and then the the articles that came out this last year looking at kind of this speech intelligibility cut off and what the criterion should be for fitting hearing aids. So the purpose of the Fast Track grant, which stands for I'm going to look at it because I can't remember finding appropriate solutions to treat reduced audibility in kids. The purpose of that grant is to focus on improving diagnosis and intervention for children with mild hearing loss. And one of our I would say one of our goals is to try to do like we're a little bit of, I don't know, one of our crazy goals is to try to get rid of the term mild hearing loss, although I still find myself using it all the time. But we would we would like to just get rid of that term because it's a misnomer.

Beth: [00:27:33] It's so true, I hate it.

Carrie: [00:27:35] I use educationally significant at times, because I feel like that can be very broad in the degrees of losses, but and the way that is so deceiving.

Beth: [00:27:49] Yeah and we're trying to do we use educationally. That's what I've always said to use the term educationally significant. The other thing that we're advocating for audiologists to do in counseling is to talk about what is the child's speech intelligibility index, because to us, that seems like a really salient concept to parents. Like how much access does this child have without hearing aids? The speech spectrum, which is what the can give you, and then how much access do they have with their hearing aids? So you can have a kid with a mild hearing loss. We looked at our data set, and if we took all of our mild kids, the average was around 0.6. So they on average, kids with mild hearing loss access to about 60% of the speech spectrum. And with hearing aids, they have access to about 90 to 95% of speech. Wow. And and we feel like that concept can really click with parents. Because one thing again, as a clinical audiologist, I used I was at the VA a long, long time ago and people would always come in and they'd say, what percentage hearing loss do I have? And that would drive me nuts because I'm like, well, we don't measure hearing loss as a percentage. And I'd always cringe when I get that question or I'd have someone come in and say, well, the doctor told me I have a 50% hearing loss. I'm like, where did you get that? Like where? Who told you that? But then I started realizing when we were really looking this stuff. I mean, that really is what the Speech Intelligibility Index is telling you. It's not saying you have a 50% hearing loss, but it's saying that's how much access you have to the speech spectrum and close when you're close to the speaker at a conversational level.

Beth: [00:29:28] So it's not taking into effect background noise and that's why I think it's a good concept for counseling with parents, because you can say, okay, when you're speaking to them from a meter away at a conversational level, they'll be able to pick up maybe about 60% of what you say when you add in background noise, when you walk further away from your child. That is going to go down and they're not going to have they're going to have access to maybe 20% of the speech spectrum. And this is a kid with a mild hearing loss. So so I think that it's I think that the is brilliant and I love it. And we talk in my lab about how we have an audibility cult because we talk about audibility all the time in my research lab. But but I just think it makes sense to families, like to parents. And it makes sense to teachers too.

Carrie: [00:30:21] Yeah. It's just we. And maybe that goes into my next question is, you know, we know that these different factors need to be in place to optimize our opportunities for children who have different degrees of hearing loss, who are wearing hearing aids. But what advice or would you give audiologists out there right now? Um, obviously, maybe joining your audiology speech intelligibility index called yes, might be one.

Beth: [00:30:55] Like us on Facebook.

Carrie: [00:30:58] Yes so we all have to join the the speech intelligibility court. But like what advice would you give to audiologists right now?

Beth: [00:31:09] So one thing we're trying to talk to audiologists about, and this is kind of I mean, this would be changing practice patterns, but you can measure the you know, it doesn't have to be part of the hearing aid fitting appointment. You can do the diagnostic testing with the baby. Um, like with ABR or when we when you do when the baby is six months old, you can get their threshold. You can plug that into a therapist or some other machine and it'll calculate the for you. And so you could use that. You can put it in their report. You can talk to the parents about it. It doesn't have to be tied into the hearing aid appointment. It can be part of the diagnostic appointment as well. But that would take a pretty big change because a lot of audiologists may not have access to the audio scan. The machine that we use to calculate the and especially at the diagnostic appointment, like you just may not have one handy, so you can't really punch the number in one thing. I know Boystown, and I'm probably going to totally explain this wrong because I don't know the details. I know Boystown has been developing a program they call sharp that would be like an app that you could use to calculate the speech intelligibility index.

Beth: [00:32:24] So but yeah, to have it be more a part of the diagnostic visit would be one big change that we haven't really been doing. The other thing that I think is really important is making sure that we're using either or measures when we're fitting the hearing aids or simulated really, or measures like measuring the and babies, as opposed to using things like aided speech aided sound field testing, or what we call functional gain when we're doing hearing aid fitting. So the big thing that we found in this study was there was huge variability in how well fit the kids hearing aids were. So we had some kids who were fit to target, fit to prescriptive targets for their hearing aids. And we had other kids that were way off target. And and the thing that we found, this was a paper by Ryan McCreary, Ruth Bentler, and Pat Roush. I think, again, it might have been in like 2013 or 2014 that was published in the ear and hearing. But one of the things they found was it had to do with how the audiologists were fitting the hearing aids. If they were using on real ear measures or simulated ear measures to program the. The hearing aids tended to be fit closer to target and that may be an underfit or overfit almost entirely. We had very that we've had very, very few kids that we've seen that were overfit, like a couple out of 317 children who were seen across multiple visits.

Carrie: [00:33:57] So they were wearing earplugs at that point?

Beth: [00:33:58] They were essentially wearing earplugs. Yep. Yeah. Yeah.

Beth: [00:34:01] So, well, I don't know. I don't want to make it that extreme. I don't know if they were mean. They were probably getting some audibility. It just wasn't to the and we were using as our targets the targets, the desired sensation level. Yeah. They were just below target.

Carrie: [00:34:19] Okay yeah. So what about parents. What would you what kind of advice would you give parents who have these kids with mild degrees of hearing loss?

Beth: [00:34:30] So one of the big things I would say is don't rely on their articulation skills, their speech production, to tell you if they're doing okay. Because one thing we found really across all of our kids with mild to severe hearing loss, but especially the kids with mild to moderate hearing loss, their speech production sounds really good. They're very intelligible. And people take those speech production skills as a sign that they're catching everything. They their language is fine, because sometimes it's kind of hard to differentiate between speech and language. And so we would see these kids that had great articulation, perfectly intelligible speech. And then but they would have these underlying language deficits in areas like morphology. So adding word endings, grammatical markers, um, that seems to be a weakness. We've also seen some weaknesses in vocabulary, and our theory is that that's going to cascade into to like problems with reading comprehension, because vocabulary and grammar are so important for reading comprehension once you get to junior high in high school. So we don't have evidence for that yet, but we suspect that that's what's going to happen. So so that would be one of the big things is and I would say that for speech pathologists too, like just because they've met, they can do the Goldman Fristoe test of articulation and not have any errors on it doesn't mean that they need to be out of out of speech therapy. Speech language therapy mean there's this whole language component to it too.

Beth: [00:36:01] The other thing I would say that we've found is just how important self-advocacy is teaching these kids pretty early on to take care of their equipment, that it's a part of them that that they like. By the time they get to elementary school, they can be doing things like checking the batteries, and they do need to wear the devices. So but also being able to advocate for themselves in the classroom, with their peers, with other teachers. I think that self-efficacy piece is just so important. And some of the kids I've worked with are just so amazing at the self-advocacy. Like, I just love seeing them because one of my favorite, I'll tell you a little story. Um, I always say this when I'm giving talks. We had this little girl and I think she was in first grade at the time, and so for a school project, she had to talk about something that was special about her, and she picked her ears, and she had her teacher take a picture of her ears with her hearing aid on. And, and she wrote this little passage and it said, can't remember. It was like, my ears are wet, make my ears are what make me unique. My hearing aids help me hear it was it was something like that. And it just I loved how mean she was only like seven years old, but it was just like she knew that was something that made her special, like in a good way and she wanted to talk about it and share, trying to talk about it. Yeah, yeah.

Beth: [00:37:24] So we can empower them early on. Then hopefully when they get to that junior high or middle school period of time, then it's become a part of them instead of like, I'm going to take them off and I don't need them and should be embarrassed of it. Exactly. We had had one girl who was in junior high, and we saw her not too long ago and said, I was just like, well, so what do people say about your hearing aids? She's like, oh, I tell everybody that it's this cool wearable device like a Fitbit, but it's just on my ear, oh, I love that.

Beth: [00:37:54] And she's like, so everybody at school thinks it's really cool. Oh yeah, I'll have to remember that one. Yeah, yeah. It's too wearable.

Carrie: [00:38:03] So my one of my other last questions would be like what would you tell advice for educators or SLPs who are in the schools about mild hearing loss?

Beth: [00:38:15] One thing so I already said the thing about articulation another okay, so there's kind of two things. One thing that we've found that I think speech pathologists and teachers should be aware of is that we do see this weakness in morphosyntax or grammar, particularly high frequency, high pitched, low intensity sounds. So English is not a very friendly language to hearing loss. So because like a lot of the English morphological markers are these very high pitched sounds like s. So plurals past tense ed third person singular, like he walks to the store. Those are really hard sounds. They're just not very salient. We have we say they don't have a lot of phonetic content, and so it's hard for these kids to be able to perceive those sounds. So they may be able to produce an s sound pretty well, but they may be not necessarily recognizing when you need to use a plural marker, when you need to use these different grammatical markers. So paying attention to morphosyntax is really important. Another thing that we've found can say a lot of things, but because get very excited about this topic. Is a with vocabulary we've found. And this again this doesn't just apply to mild hearing loss.

Beth: [00:39:34] But we've seen this with kids with mild hearing loss. We have different measures we use to measure vocabulary. The common one is the Picture Peabody Picture Vocabulary test, which is a receptive language measure where you see different pictures on a page. You hear a target word, you're supposed to point to it the problem and love the Peabody gets great measure. The problem with that is it's really only testing their surface level knowledge of words and how it's testing how many words they know, but it's not really getting at how much do they actually know about those words? What's the depth of their knowledge. So one thing we've found is that how much access they have to the speech spectrum through their hearing aids, again, all comes back to see will predict their long term growth in the depth of their vocabulary knowledge. So we and we see that they just kids with mild and moderate and severe hearing loss seem to they seem to be catching up over time in terms of how many words they know, but they never quite catch up and how much they know about words. The depth of their knowledge and their audibility seems to be really tightly linked to that.

Beth: [00:40:41] So and then there was one other thing with the mild hearing loss that I wanted. Oh, okay. So then this other thing that we found that's really think is very interesting, we've seen this consistent pattern with our mild kids where they're we call it we call it our sweet spot. So our kids with moderate hearing loss on average look just like our typical hearing kids. The kids with mild hearing loss are just a little bit below that. So and then the kids with severe hearing loss have more of a deficit. And so we call these kids with moderate hearing loss our spot. And we think that's kind of because they're probably getting pretty consistent intervention. They're wearing the hearing aids and they can be fit appropriately for their hearing loss. Whereas the kids with mild hearing loss, it's almost not enough. It's not enough of a delay to cause a concern, but enough that I'd be worried they'd fall through the cracks. Okay, so they're just kind of like coasting along, but don't think they're reaching their full potential. And that is probably the result of maybe not wearing the hearing aids or not being fit with hearing aids and maybe not getting consistent special education services.

Carrie: [00:41:56] So getting over time, that gap probably widens.

Beth: [00:42:00] And that's what our question. Yeah. We wondered. That's why we want to look at them in adolescence. Because we do wonder if that gap widens over time or not. Because right now it just it's just this like you can see it if you look at any of our papers, especially the last couple of years, we've been publishing on how these kids are doing in second and fourth grade. And you can see this trend where it's just the mild kids are just a little bit lower than the moderate kids, but they really should be at the same level. They should be performing at the same level as and that we see that especially in Morphosyntax, but we also see it in vocabulary measures and reading comprehension measures. So but we haven't really tested the kids past fourth grade, so we don't know what happens after fourth grade.

Carrie: [00:42:50] Okay.Which is why you need to get this other grant.

Beth: [00:42:55] No so don't get in trouble. I don't think there's anything like where you can't talk about a grant that you just submitted. I think I'm allowed to do that.We didn't talk that much. There's no embargo or anything, but.

Carrie: [00:43:10] So is there anything that I didn't ask you that you want to make sure our listeners know whether they're parents or educators or speech pathologist or audiologist or just anyone out there.

Beth: [00:43:25] I guess I would just say, oh, I don't know. I feel like I should come up with something really profound here. And I'm not nothing's really coming to mind. But don't overlook these kids with these mild to severe hearing loss. That is our big take home message that we do. We can see that these kids can like going back to what our original question was, the way we started off the podcast today, what was the original purpose of this longitudinal study was to see, can these kids keep up with their same age peers, and what are the factors that seem to support resilience? Kids that are keeping up versus the kids that are falling behind. And and it really seems to get back to we can kids can definitely keep up these kids with mild to severe hearing loss. They can do as well as their same age peers. But but it's not. But they can't just do it on their own. Like we need the support of teachers, speech pathologists, parents. We need to be teaching these kids, like I said, these self-advocacy skills and and realizing. Again. Like what you said, the the device is just a part of them and they're going to need that in order for the classroom to be accessible. That's going to be a part of life. But but they can succeed. They can meet. They can meet high, high goals, whatever the parents goals have for them. And I've definitely seen that with these kids that have been in this study, they've done amazing things.

Beth: [00:44:48] Yeah.

Carrie: [00:44:49] No, I'm so thankful for all of the information that you have and all of the resources that your group has pulled together and made accessible and the websites, and I'm going to post that in the show notes, too, and on the Facebook page so that people can click on that and get all of your amazing brochures.

Beth: [00:45:09] And oh yeah, I was going to say, make sure you post something about the infographics.

Carrie: [00:45:13] And we have infographics.

Beth: [00:45:16]I know we do. We love infographics. And we spent a lot of time coming up with these infographics and they are available still we have money. Phonak donated money to us so that we could ship the infographics to whoever wants them. And so we still have some of that money left. And so if you just go to our web page W-w-w dot social study.org, which Carrie will post in the show notes, I will you can there's like a little thing you can click if you want any of the infographics for your office, for your home.

Carrie: [00:45:52] To share with family.

Beth: [00:45:52] To share with family.

Carrie: [00:45:56] So they have valuable right? And you can download them as well. And you can email them.

Beth: [00:46:01] And we have them in like six different languages. Now, it's funny because I think every time I give a talk, somebody comes up to me afterwards and they're like, I can translate that into Dutch for you or Arabic or Mandarin. So. So yes, they've been translated into multiple languages as well.

Beth: [00:46:18] Good.

Carrie: [00:46:19] So it's very much accessible.

Beth: [00:46:21] Yes, very. Infographics are very accessible.

Carrie: [00:46:25] Well that's good, but I just want to thank you for coming on to the Empower Your podcast today. I hope our listeners gained a good perspective. That mild is not my old and that we really need to look at these kids in a different way so that they can reach their fullest potential. And they they can. It's just a matter of how we approach it and how we support them and and everything else that kind of goes into that village and that that whole child. So again, Beth, I am so thankful for you coming on today, and I really appreciate everything that you had to share and all of the work that you do. It's very valuable.

Beth: [00:47:06] Thank you. I cannot wait to see you in person at Asha someday or some other conference. I'm missing you.

Carrie: [00:47:18] Thank you.

Beth: [00:47:19] Yes. Thank you.

Announcer: [00:47:21] This has been a production of the 3C Digital Media Network.